INITIAL and ANNUAL TUBERCULOSIS SCREENING QUESTIONNAIRE
(This Form is to be used for those with a previously positive TB Skin Test, i.e., positive PPD.)
First Name:________________________ Middle Initial:____ Last Name:_________________________
Positive TB Skin Test (PPD Date):__________________________
Date of Last Chest X-Ray:________________________________
Please indicate if you have had any of the following conditions for three to four weeks or longer:
SIGN OR SYMPTOM
YES
NO
Chronic Cough (greater than 3 weeks)
Production of Sputum (productive cough)
Blood Streaked Sputum
Unexplained Weight Loss
Unexplained Fever
Weakness/Fatigue/Tiredness
Loss of Appetite
Night Sweats
Shortness of Breath
Chest Pain with Coughing
Rapid Heart Rate (Tachycardia)
NO EVIDENCE OF PULMONARY TUBERCULOSIS OR CONTAGIUM.
Applicant/Healthcare Associate Signature:_______________________________
Date:_____________
Physician Signature:_________________________________________________
Date:_____________
License Number_________________________________________________________________________
Clinic/Office Address:_____________________________________________________________________
Clinic/Office Telephone Number: ___________________________________________________________
© 2012 ATC Healthcare Services, Inc.